Neumología en la Comunidad de Madrid. Nunca es tarde para garantizar una asistencia neumológica de calidad contrastable / No disponible

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Analysis of patients referred to a lung transplantation unit.

This cross-sectional, concurrent and descriptive study presents the decisions regarding patients referred to our Lung Transplantation Unit (LTxU). Each patient is discussed in a multidisciplinary clinical session (phase I), rejecting some and accepting others for assessment in our LTxU (phase II) according to criteria of the National and International Guidelines for Transplantation. A protocol assessment in phase II, leads to a decision to reject, accept, or follow-up the candidate for LTx. Among 214 evaluation requests received in our unit from May 2008 to December 2011, 37 patients (17%) were rejected based on the information sent to our LTxU. Among the patients evaluated in phase II, 62 (28.9%) were put on the waiting list, 125 (58.4%) were rejected, and twenty-seven (12.6%) were postponed for future reconsideration, results that were similar to those described in the literature. The main disease referred for LTx was obstructive airflow (n = 98; 45.7%), followed by interstitial lung disease (ILD; n = 66; 30.8%), cystic fibrosis or bronchiectasis (n = 20; 9.3%), or primary pulmonary hypertension group 1 (n = 20; 9.3%). Ten patients (4.6%) were diagnosed with other respiratory diseases. Most patients (n = 165; 77.1%) lived in the region of our hospital (Madrid). The main reasons to reject patients for LTx were malnutrition, severe disease in other organs, toxic habits, and refusal of treatment. Finally, one out of four referred patients was accepted for LTx. In addition to serious comorbidities in various organs, a high percentage of patients who were not accepted for LTx because of these factors might have been of accepted had these conditions been corrected before patient referral.

Composite anatomical-clinical-molecular prognostic model in non-small cell lung cancer.

The objective of the present study was to elaborate a survival model that integrates anatomic factors, according to the 2010 seventh edition of the tumour, node and metastasis (TNM) staging system, with clinical and molecular factors. Pathologic TNM descriptors (group A), clinical variables (group B), laboratory parameters (group C) and molecular markers (tissue microarrays; group D) were collected from 512 early-stage nonsmall cell lung cancer (NSCLC) patients with complete resection. A multivariate analysis stepped supervised learning classification algorithm was used. The prognostic performance by groups was: areas under the receiver operating characteristic curve (C-index): 0.67 (group A), 0.65 (Group B), 0.57 (group C) and 0.65 (group D). Considering all variables together selected for each of the four groups (integrated group) the C-index was 0.74 (95% CI 0.70-0.79), with statistically significant differences compared with each isolated group (from p = 0.006 to p < 0.001). Variables with the greatest prognostic discrimination were the presence of another ipsilobar nodule and tumour size > 3 cm, followed by other anatomical and clinical factors, and molecular expressions of phosphorylated mammalian target of rapamycin (phospho-mTOR), Ki67cell proliferation index and phosphorylated acetyl-coenzyme A carboxylase. This study on early-stage NSCLC shows the benefit from integrating pathological TNM, clinical and molecular factors into a composite prognostic model. The model of the integrated group classified patients with significantly higher accuracy compared to the TNM 2010 staging.

Experiencia de los últimos 17 años en una unidad de endoscopia respiratoria / Respiratory endoscoscopy department experience in the last 17 years

Objetivo. Describir la actividad de una de las primeras unidades de endoscopia respiratoria (UER) de nuestro país analizando las indicaciones y técnicas de broncoscopia diagnóstica y terapéutica, y si se han modificado a lo largo de los años. Material y métodos. Estudio transversal de todas las broncoscopias realizadas en nuestra UER desde 01/1992 hasta 05/2009. Para analizar la evolución de las indicaciones dividimos a la población general en cuatro poblaciones agrupadas por orden cronológico según la fecha de la exploración. Para analizar las diferencias en la frecuencia de las distintas técnicas a lo largo del tiempo empleamos el coeficiente Chi cuadrado de Pearson, aceptando como significativo un valor de p < 0,05. Resultados. 30.359 exploraciones (1.785 exploraciones/año); programadas 84,4% y urgentes 15,6%. De éstas, 26.277 (86,5%) fueron diagnósticas, 2.668 (8,8%) terapéuticas y 1.414 (4,6%) intubaciones. Se ha producido un descenso estadísticamente significativo del número de biopsias y cepillados bronquiales con un incremento significativo de las biopsias y punciones transbronquiales. Se han colocado 890 prótesis endoluminales y se han realizado tratamientos con láser en 429 casos. El porcentaje de complicaciones ha sido escaso (0,5%) y la tolerancia de los pacientes con anestesia local fue considerada buena en el 91,1% de casos. Conclusiones. El número de broncoscopias realizadas en nuestra UER es elevado, en especial las terapéuticas. Las indicaciones y técnicas realizadas se han modificado a lo largo de los años de acuerdo con la evolución de la técnica y los cambios de incidencia de diferentes patologías neumológicas (AU)

AIM. To describe the activity of one of the first Respiratory Endoscopy Departments in Spain, analyzing different techniques and indications of flexible and interventional bronchoscopy and its modifications over the years. Material and methods. Transversal study of all bronchoscopies carried out between 01/1992 and 05/2009. To analyze the different techniques along this period, the whole population was divided in four groups according to the date of the technique. The Pearson Chi square trend test was used for statistical comparisons, with p<0.05 considered to indicate a significant result. Results. 30,359 examinations (1,785 examination per year) were done; 84.4% programmed and 15.6% emergencies. For these 26,277 (86.5%) were diagnosis, 2,668 (8.8%) therapeutic and 1,414 (4.6%) intubations. There was a statistically significant decrease of bronchial biopsies and brushings and a statistically significant increase of transbronchial biopsies and punctures. 890 tracheobronchial endoprothesis were placed and 429 laser therapies were executed. Few complications were registered (0.5%) and thopic anaesthesia was well tolerated by most patients (91.1%). Conclusions. The global number of bronchoscopies done in our department is quiet large, especially therapeutic ones. Over the years, indications and different techniques have changed, according to technique evolution and different lung diseases (AU)

Cáncer de pulmón. Novedades en la estadificación TNM en 2009 / Lung cancer. Novelties in TNM staging in 2009

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La ‘residentalización’ del alumno / The ‘residentialization’ of the student

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Rentabilidad de la broncoscopia en el diagnóstico de lesiones pulmonares focales malignas / Profitability of the bronchoscopy in the diagnosis of focal pulmonary malignant lesions

Introducción. Definimos lesión pulmonar focal (LPF)como lesión pulmonar intraparenquimatosa, biencircunscrita y completamente rodeada por pulmónsano. Se considera que la rentabilidad de la puncióncon aguja fina (PAAF) en LPF 2 cm es mejor quela de la fibrobroncoscopia (FBC).Objetivo. Analizar la rentabilidad diagnóstica de laFBC en la LPF maligna y estudiar si varía segúnlocalización, tamaño e histología.Material y métodos. Analizamos todas las FBC denuestra Unidad entre enero de 2000 y diciembrede 2001 en pacientes con LPF única 6 cmcon diagnóstico definitivo de malignidad. Larentabilidad diagnóstica por tamaño, localización ehistología se analizó con el estadístico χ2 de Pearson.Resultados. 124 pacientes. La media de FBC porpaciente fue de 1,3. 101 casos (82%) sediagnosticaron con FBC; 15, por toracotomía y 8,por PAAF. La rentabilidad diagnóstica global de laFBC fue 0,82 y de la biopsia transbronquial 0,76.No hay diferencias de rentabilidad diagnóstica portamaño ( 2 cm frente a > 2 cm) (0,81 frentea 0,82 p = 0,96), localización (periférico frente acentral) (0,79 frente a 0,85 p = 0,41) e histología(epidermoide frente a adenocarcinoma) (0,89 frentea 0,75 p = 0,21).Conclusión. La rentabilidad de la FBC en LPFmaligna en nuestro hospital es elevada sindiferencias por tamaño, localización o histología. Ennuestro centro la aproximación diagnóstica inicial dela LPF se realiza con FBC

Introduction. We define focal pulmonary lesion(FPL) as an intra-parenchymatous pulmonary lesionthat is well circumscribed and completelysurrounded by healthy lung. It is considered that theprofitability of the fine needle aspiration puncture(FNAP) in FPL 2 cm is better than that of thefibrobronchoscopy (FBC).Objective. To analyze the diagnostic profitability ofthe FNAP in the malignant FPL and study if it variesaccording to site, size and histology.Material and methods. We analyzed all the FBCs ofour Unit between 01/2000 and 12/2001 in patientswith solitary FLP 6 cm with a definitive diagnosisof malignancy. The diagnostic profitability by size,site and histology was analyzed with Pearson’s χ2statistics.Results. 124 patients. Mean FBC per patient was1.3. A total of 101 cases (82%) were diagnosed withFBC, 15 by thoracotomy and 8 by FNAP. Globaldiagnostic profitability of the FBC was 0.82 and thetransbronchial biopsy 0.76. There are no diagnosticprofitability differences by size ( 2 cm vs > 2 cm)(0.81 vs 0.82 p = 0.96), site (peripheral vs central)(0.79 vs 0.85 p = 0.41) and histology (epidermoidvs adenocarcinoma) (0.89 vs 0.75 p = 0.21).Conclusion. Profitability of the FBC in malignantFPL in our hospital is elevated without differencesby size, site or histology. In our site, the initial diagnostic approach of the FLP is done with FBC (AU)

Análisis de marcadores moleculares en carcinoma broncogénico no microcítico resecado: Estudio de sesgos de selección y expresión según la histología / No disponible

Objetivos: Evaluar un potencial sesgo de selección poblacional en un estudio de expresión proteica en carcinoma broncogénico no microcítico resecado (CBNM) y realizar un análisis de la expresión molecular global y la específica según la estirpe histológica. Población y métodos: estudio observacional, de cohorte, concurrente, de todos los pacientes con CBNM tratados quirúrgicamente en nuestro Hospital entre octubre de 1993 y septiembre de 1997. Elaboramos matrices de tejido en tumor resecado y la expresión proteica se estudió mediante inmunohistoquímica. La población se dividió entre los que se pudo efectuar estudio molecular (población A) y el resto (población B). El análisis de sesgos se realizó con el test Chi cuadrado para variables cualitativas, la T de Student para cuantitativas y el Kaplan-Meier para curvas de supervivencia. Las diferencias de expresión proteica según la histología se analizaron con el test Chi cuadrado. Resultados: 180 casos totales. En 146 existía material suficiente para el estudio (población A) y en 34 no (población B). No hay diferencias significativas entre las poblaciones excepto que los casos de la población B eran más pequeños (3,3 cm vs 4,5 cm) (p= 0,04) con menos neumonectomías (t 1,8% vs 3t,6%) (p= 0,02). La estirpe más frecuente es taepidennoide (68%), De las 32 proteínas estudiadas, 8 se expresan más en epidennoides (ciclina A, CDK6, RB, p63, survivina N, EGFR, mTORp, p53) y 3 en adenocarcinomas (survivina C, ligando FAS y Cdc6). Conclusiones: Nuestra muestra representa a la población seleccionada sin que exista un sesgo de selección inicial de la suficiente magnitud como para comprometer sus resultados. En este estudio, 11 marcadores se expresan de forma diferente en función de la estirpe histológica del CBNM (AU)

To evaluate a population’s potential selection bias in a study of protein expression in resected NSCLC and to perform an analysis of global and specific molecular expression according to histological type. Population and methods: An observational, cohort, concurrent study in all patients with NSCLC surgically treated in our hospital between October 1993 and September 1997. Tissue arrays were designed from samples of resected tissue. The study method used for the evaluation of protein expression was immunohistochemistry. Population was divided into groups: patients with a molecular study (population A) and the rest (population B). Bias analyses was performed using the Chi square test for qualitative variables and the student T test for quantitative variables; the Kaplan-Meier test was used to compare survival curves. The Chi square test was used to analyse expression dijferences in proteins depending on the histological type. Results: Of total 180 cases, 146 had enough material for molecular study (population A) and 34 did not (population B). There were no differences between both populations, with the exception that tumours in population B were smaller (3.3 cm vs 4.5 cm) (p= 0.04) and with a lower frequency of pneumonectomies (11.8% vs 31.6%) (p= 0.02). The epidermoid histological type is the most frequent (68%). Of the 32 proteins studied, 8 are more frequently expressed in epidermoid types (cyclin A. CDK6, RB, p63, survivin N, EGFR, mTORp, p53) and 3 in adenoearcinomas (survivin C, FAS ligand and Cdc6). Conclusions: Our sample is representative of the selected population with no initial selection bias large enough to compromise the results. In this study, 11I markers were expressed differently according to the histological type of the NSCLC (AU)

[Profitability of the bronchoscopy in the diagnosis of focal pulmonary malignant lesions]. / Rentabilidad de la broncoscopia en el diagnóstico de lesiones pulmonares focales malignas.

INTRODUCTION: We define focal pulmonary lesion (FPL) as an intra-parenchymatous pulmonary lesion that is well circumscribed and completely surrounded by healthy lung. It is considered that the profitability of the fine needle aspiration puncture (FNAP) in FPL < or = 2 cm is better than that of the fibrobronchoscopy (FBC). OBJECTIVE: To analyze the diagnostic profitability of the FNAP in the malignant FPL and study if it varies according to site, size and histology. MATERIAL AND METHODS: We analyzed all the FBCs of our Unit between 01/2000 and 12/2001 in patients with solitary FLP < or = 6 cm with a definitive diagnosis of malignancy. The diagnostic profitability by size, site and histology was analyzed with Pearson's chi(2) statistics. RESULTS: 124 patients. Mean FBC per patient was 1.3. A total of 101 cases (82%) were diagnosed with FBC, 15 by thoracotomy and 8 by FNAP. Global diagnostic profitability of the FBC was 0.82 and the transbronchial biopsy 0.76. There are no diagnostic profitability differences by size (< or = 2 cm vs > 2 cm) (0.81 vs 0.82 p = 0.96), site (peripheral vs central) (0.79 vs 0.85 p = 0.41) and histology (epidermoid vs adenocarcinoma) (0.89 vs 0.75 p = 0.21). CONCLUSION: Profitability of the FBC in malignant FPL in our hospital is elevated without differences by size, site or histology. In our site, the initial diagnostic approach of the FLP is done with FBC.

Expression signatures in lung cancer reveal a profile for EGFR-mutant tumours and identify selective PIK3CA overexpression by gene amplification.

The development of targeted therapies creates a need to discriminate tumours accurately by their histological and genetic characteristics. Here, we aim to identify gene expression profiles and single markers that recapitulate the pathological and genetic background of non-small cell lung cancer (NSCLC). We performed cDNA microarray analysis on a series of 69 NSCLCs, with known mutation status for important genes, and six normal lung tissues. Unsupervised cluster analysis segregated normal lungs from lung tumours and lung tumours according to their histopathology and the presence of EGFR mutations. Several transcripts were highly overexpressed (by approximately 20 times) in squamous cell carcinomas (SCCs) relative to adenocarcinomas (ACs) and confirmed by immunohistochemistry in an independent cohort of 75 lung tumours. Expression of 13 genes constituted the most prominent hallmarks of EGFR-mutant tumours, including increased levels of proline dehydrogenase (PRODH) and down-regulation of X-box binding protein 1 (XBP1). No genes were differentially expressed, with a fold change >or= 4 or

Neumotórax espontáneo, neumomediastino y enfisema subcutáneo en paciente VIH con probable neumonía por Pneumocistis jiroveci / Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in HIV patient with probable pneumonia due to pneumocistis jiroveci

neumotórax es una complicación frecuente en pacientes con el síndrome de inmunodeficiencia adquirida (VIH), yaque ocurre en más del 2% del total, y este porcentaje se incrementa al 5-10% en aquellos casos con infección activa o pasada por Pneumocistis jiroveci (PJ), anteriormente llamado carinii. La etiología no está aclarada y se ha relacionado con diversos factores tales como la propia infección por PJ o tuberculosis, o bien con el tratamiento inhalado con pentamidina.Puede acompañarse de neumomediastino y enfisema subcutáneo. No hay tratamiento de elección, y éste varíadesde el manejo conservador al tratamiento quirúrgico. Presentamos el caso de un adulto con infección VIH al que se diagnóstico de probable infección por PJ, y que en el curso de la infección presentó neumotórax derecho, neumomediastino y enfisema subcutáneo, que evolucionó favorablemente con tratamiento conservador

Spontaneus pneumothorax is a frequent complication in patients with acquired immune deficiency syndrome (AIDS)that may ocurr in up to 2% of patients and this percentage increases to 5-10% in those patients with current or previous Pneumocystis jiroveci pneumonia (PJP) previously called Pneumocystis carynii. The etiology is unknown but it has been related with infectious diseases like PJP, mycobacterium tuberculosis or aerosolized pentamidine treatment. Sometimesthere could be pneumomediastinum or subcutaneus emphysema. The treatment is not clear and it could ranged between clinical observation to surgical treatment. We present a case report of an adult with AIDS and probably PJP with right pneumothorax, pneumomediastinum and subcutaneus emphysema solved without invasive treatmen (AU)

Actualización en cáncer de pulmón. Clasificación y algoritmo de estadificación / Up-date in lung cancer. Classification and algorithm of stratification

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Tratamiento multimodal en el carcinoma broncogénico no microcítico (N2) clínico: ¿cuál es la respuesta? / Multimodal treatment of clinical non-small cell N2 bronchogenic carcinoma. What is the answer?

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Normativa sobre valoración del riesgo quirúrgico en el carcinoma broncogénico / Guidelines for the Evaluation of Surgical Risk in Bronchogenic Carcinoma

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Carcinoma broncogénico microcítico y síndrome de Peutz-Jeghers / Non-small cell bronchogenic carcinoma and Peutz-Jeghers Syndrome

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[Lymphoid interstitial pneumonia resolved through antiretroviral therapy in an adult infected by human immunodeficiency virus]. / Neumonía intersticial linfoidea en un paciente adulto con infección por el VIH, resuelta con tratamiento antirretroviral.

Lymphoid interstitial pneumonia (LIP) is a rare entity characterized by the infiltration of interstitial tissues and alveolar spaces by lymphocytes, plasma cells, and other lymphoreticular structures. The etiology of LIP is unknown, although associations with autoimmune and infectious factors have been described. The incidence of LIP has risen in recent years, mainly in children with acquired immunodeficiency syndrome (AIDS), while remaining less common in the adult population. No agreement has been reached regarding the diagnostic tests necessary for a firm diagnosis although suspicion is usually based on clinical and radiographic findings, with confirmation provided by examination of histological samples. The most common treatment is corticosteroids, either alone or in combination with other immunosuppressant agents although no evidence from controlled trials is available and cases have been reported in which LIP resolved in AIDS patients with antiretroviral therapy alone. We report the case of a human immunodeficiency virus-infected adult who was diagnosed with LIP by open lung biopsy and who responded to antiretroviral drugs with no need for associated corticosteroid therapy.

Neumonía intersticial linfoidea en un paciente adulto con infección por el VIH, resuelta con tratamiento antirretroviral / Lymphoid interstitial pneumonia resolved through antiretroviral therapy in an adult infected by human immunodeficiency virus

La neumonía intersticial linfoidea es una entidad poco frecuente, caracterizada por la infiltración del intersticio y los espacios alveolares por linfocitos, células plasmáticas y otros elementos linforreticulares. Su etiología es desconocida y se asocian factores autoinmunitarios e infecciosos. La incidencia ha aumentado en los últimos años, fundamentalmente en niños y en relación con el síndrome de la inmunodeficiencia adquirida, siendo más rara en la población adulta. No hay acuerdo en cuanto a las pruebas diagnósticas necesarias para su confirmación, aunque la sospecha suele basarse en datos clínicos y radiológicos, y debe confirmarse con muestras histológicas. El tratamiento más empleado son los esteroides, bien solos o en combinación con otros agentes inmunodepresores, aunque no hay ensayos controlados y se han descrito casos de pacientes con sida resueltos con tratamiento antirretroviral exclusivamente. Presentamos el caso de un adulto con infección por el virus de la inmunodeficiencia adquirida al que se diagnosticó de neumonía intersticial linfoidea en nuestro servicio mediante biopsia pulmonar abierta y que se resolvió con antirretrovirales sin precisar de tratamiento esteroideo asociado (AU)